Reading of the Week: Insomnia and Its Treatment

Cognitive behavioral therapy for insomnia (CBT-I) is a multicomponent treatment package that usually includes stimulus control, sleep restriction, and cognitive therapy and has emerged as the most prominent nonpharmacologic treatment for chronic insomnia. Previous meta-analyses have found that CBT-I improves sleep parameters and sleep quality at post treatment and follow-up for adults and older adults. Most of these studies selected individuals with primary insomnia, excluding patients with co-morbid psychiatric and medical conditions. However, patients with insomnia who present to internists and primary care physicians are likely to report comorbid conditions associated with the sleep disturbance. Furthermore, insomnia was previously conceptualized as a symptom arising from the comorbid disorder and treatment was targeted at the underlying disorder. However, accumulating evidence indicates that insomnia can have a distinct and independent trajectory from the comorbid disorder, thus indicating a need for separate treatment from the comorbid condition.

So begins this week’s Reading, which considers CBT-I for people with insomnia. Here’s a quick summary: big study, big journal – and big relevance to your patients.

This week’s Reading: “Cognitive Behavioral Therapy for Insomnia Comorbid With Psychiatric and Medical Conditions: A Meta-analysis” by Jade Q. Wu et al. was just published in JAMA Internal Medicine. Find the paper here.

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Wu et al. consider a very common problem: insomnia. Many patients – whether they have mental health issues or physical health issues – struggle with insomnia. Boston University health economist Austin Frakt has written about his insomnia for The New York Times. He notes that he decided to receive treatment when:

One weekend afternoon a couple of years ago, while turning a page of the book I was reading to my daughters, I fell asleep. Continue reading

Reading of the Week: ADHD and Overdiagnosis

Overdiagnosis in psychiatry occurs where patients are identified with a mental disorder when they do not have significant impairment and would not be expected to benefit from treatment. These problems can arise even when diagnostic criteria are met, that is, in the presence of milder symptoms that fall close to, or within, a normal range on a diagnostic spectrum. Overdiagnosis can lead to unnecessary labelling, unneeded tests, unnecessary therapies, and inflated health care costs. In medicine, with the best of intentions, practice has come to favour more tests and more treatments, all of which tend to drive overdiagnosis. This problem may be worsened by a prevailing cultural ethos that more is better.

Outside of psychiatry, there are clear examples of overdiagnosis. For example, screening programs designed to detect early stages of certain cancers appear to increase incidence estimates, but may have no discernable effect on mortality…

Psychiatry has followed this trend. It has been estimated that at least 40% to 50% of the population will meet criteria for at least 1 psychiatric diagnosis during their lifetime. The current system of nosology in psychiatry, based on phenomenology, that is, subjective reports and clinical observations, encourages overdiagnosis. The presence or absence of mental disorders is not defined by biomarkers, allowing diagnostic constructs to describe broad spectra that cross over into normality.

So begins a short, sharp article on overdiagnosis in psychiatry that has just been published. The authors raise significant issues about psychiatry in general and adult ADHD in particular – they argue that the DSM diagnosis is flawed and impractical; they take aim at patients (yes, patients); they then turn their sites on researchers and industry.

The comments of sensational journalists? The skewed opinion of Scientologists on a blog? Actually, the Reading comes from the pages of The Canadian Journal of Psychiatry and, for the record, the paper’s first author is one of the most prominent psychiatrists in the country; Dr. Joel Paris is the past chair of McGill’s Department of Psychiatry and the author of more than a dozen books.

This week’s Reading: “Is Adult Attention-Deficit Hyperactivity Disorder Being Overdiagnosed?” by Paris et al.

Here’s the link:

http://www.ncbi.nlm.nih.gov/pubmed/26175391

The Canadian Journal of Psychiatry has always been worth reading, but its new editor, Dr. Scott Patten, has taken this journal to the next level. And, in my opinion, this “perspective” paper is a must-read – one of the most important papers written this year. Continue reading

Reading of the Week: Depression: Is There an App for That?

Depression is a serious, common, and recurring disorder linked to diminished functioning, quality of life, medical morbidity, and mortality. There has been a 37.5% increase in health life years lost to depression over the past two decades. Depression was the third-leading cause of global burden of disease in 2004 and the leading cause of burden of disease in high- and middle-income countries. It is projected to be the leading cause globally in 2030. While effective treatments for depression are available, they are underused. Barriers to treatment include geography, socioeconomic status, system capacity, treatment costs (direct and indirect), low mental health literacy, cultural beliefs, and stigma. A 2010 study found that 75% of primary care patients with depression in urban areas could identify more than one structural, psychological, cultural, or emotional barrier to accessing behavioral treatments. The rate was substantially higher in rural areas.

So begins a new paper that considers an old problem – the difficulty of patients accessing mental health care.

But this paper is different. It considers a modern approach to access: smartphone and tablet applications (or apps) for depression. And it’s not just the topic that is so modern with this week’s Reading. Consider: the paper was published in a new journal, JMIR mHealth and uHealth, available only on-line, and focused on the very modern topic of mobile health. (This journal is a spin-off of JMIR, the Journal of Medical Internet Research, itself a relatively new journal, which boasts an impact factor of 4.7 in 2013.)

This week’s Reading: “Finding a Depression App: A Review and Content Analysis of the Depression App Marketplace” by Nelson Shen et al. In it, the authors seek to shed light on a poorly studied area. As they note early in the paper, despite the incredible popularity of apps, only one recent systemic review looked at depression apps, and included just 4 papers. And so, Shen et al. consider apps for depression, drawing out common characteristics and purposes.

This is, then, an important topic. The potential here is great: with so many of our patients empowering themselves with apps, those with depression could potentially access good information, screening tools and even treatments such as CBT.

What did Shen et al. find in their paper? It’s best summarized by the old Roman phrase caveat emptor (let the buyer beware). Continue reading

Reading of the Week: Suicide and Religion

The relationship between religion and suicide was first established in Emile Durkheim’s 19th-century seminal treatise. This has since been corroborated in different countries,most recently by Swiss researchers who used a year 2000 census-based cohort study to show that such risk patterns still persisted, with risk highest for those with no religious affiliation, lowest for Roman Catholics and intermediate for Protestants. Why religion should exhibit this protective effect is less clear: Durkheim attributed it to the sense of community that arises from active church membership, with attendance the most commonly cited attribute. Others, however, emphasise the moral and religious objections to suicide,although Durkheim was at pains to rule this out as an explanation. Perhaps a more pertinent question is why, given increasing societal secularisation, does the relationship between religion and suicide still seem to persist? Increasing secularization is also evident in Switzerland, where by the end of the 1990s nonpractising Christians made up almost half the population, and a further 11% cited no religious affiliation. This has led many social researchers, including some in Switzerland, to conclude that affiliation bears little correspondence to religious belief or practice but is more likely to reflect a diverse set of traditions or social convenience.

So begins a new paper from the British Journal of Psychiatry looking at what seems to be a very old and established relationship: religion and suicide. This is heavily treed ground, as the above quotation suggests, with work going back to Durkheim’s 1897 book.

Emile Durkheim

I remember medical school and residency conversations on this topic of religion and suicide, referencing Durkheim. Though people debated the reasons, this much seemed to be taken for granted: religion bestows a protective quality on its followers. For Durkheim, the thinking was that church attendance – highest among the Catholics – provided the advantage.

In “Religion and the risk of suicide: longitudinal study of over 1 million people,” Dermot O’Reilly and Michael Rosato focus on Northern Ireland, drawing on census data.

Dr. Dermot O’Reilly

It’s a short, clever study. It also raises a simple question: is Durkheim’s thinking dated?

Continue reading

Reading of the Week: The New Yorker Essay on De Troyer (and Carter v. Canada)

In her diary, Godelieva De Troyer classified her moods by color. She felt “dark gray” when she made a mistake while sewing or cooking. When her boyfriend talked too much, she moved between “very black” and “black!” She was afflicted with the worst kind of “black spot” when she visited her parents at their farm in northern Belgium. In their presence, she felt aggressive and dangerous. She worried that she had two selves, one “empathetic, charming, sensible” and the other cruel.

She felt “light gray” when she went to the hairdresser or rode her bicycle through the woods in Hasselt, a small city in the Flemish region of Belgium, where she lived. At these moments, she wrote, she tried to remind herself of all the things she could do to feel happy: “demand respect from others”; “be physically attractive”; “take a reserved stance”; “live in harmony with nature.” She imagined a life in which she was intellectually appreciated, socially engaged, fluent in English (she was taking a class), and had a “cleaning lady with whom I get along very well.”

So begins this week’s reading, an essay by writer Rachel Aviv that was just published in The New Yorker.

It’s a moving and tragic story of a woman who struggles with low mood. If she dreams of fluent English and a cleaning lady, her life takes a turn for the worse: after a breakup, she “feels black again.” Loss and estrangement replace hope and love. After years of struggling, the near elderly woman ultimately chooses to end her life. But she doesn’t die by her own hand; she dies in a clinic at the hands of a physician. To us Canadians, this is a story that is both familiar – involving psychiatry and medications – and unfamiliar – euthanasia and state-sanctioned doctor-assisted suicide.

De Troyer’s life and death occurs an ocean away, in Belgium. But, in light of a recent Supreme Court of Canada ruling in Carter v. Canada, a question to ask: how will doctor-assisted suicide reshape psychiatry in this country? Continue reading

Reading of the Week: NEJM and Smoking Cessation

More than 50 years after the release of the first Surgeon General’s report on the harmful effects of smoking, national policies, behavioral programs, and pharmacologic approaches have helped reduce smoking rates in the United States. However, the need for new approaches is clear because smoking remains the leading cause of preventable illness and death.

So begins a big paper from The New England Journal with a simple aim: getting people to butt out. It raises two important questions: If we are serious about promoting smoking cessation, are we willing to put ‘our money where our mouth is’ – literally? And how could we do this?

“Randomized Trial of Four Financial-Incentive Programs for Smoking Cessation” by Dr. Scott D. Halpern et al. is this week’s Reading; it has just been published.

Though other papers have been written on this topic, the Halpern et al. paper is clever and interesting – and the results are surprising.

And, don’t tell the editors of The New England Journal of Medicine: the results are also disappointing. Continue reading

Reading of the Week: Choosing Wisely and Psychiatry

The routine use of antipsychotics, like Zyprexa (olanzapine) and Seroquel (quetiapine), should not be used to treat primary insomnia in children, adults or the elderly, say Canadian psychiatrists. This information is part of a series of 13 evidence-based recommendations made by the Canadian Psychiatric Association (CPA) and its working group partners, the Canadian Academy of Child and Adolescent Psychiatry (CACAP) and the Canadian Academy of Geriatric Psychiatry (CAGP), for the Choosing Wisely Canada campaign.

Choosing Wisely Canada (CWC) is a campaign to help physicians and patients engage in conversations about unnecessary tests, treatments and procedures, and to help physicians and patients make smart and effective choices to ensure high-quality care.

So begins the press release announcing the 13 recommendations made jointly by these three bodies as part of Choosing Wisely Canada.

The full list is this week’s Reading, and “Thirteen Things Physicians and Patients Should Question” can be found here:

http://www.choosingwiselycanada.org/recommendations/psychiatry/

Choosing Wisely is a good campaign – thoughtfully done and executed. It ultimately aims to better patient care. It’s also important within the context of the larger system itself. Continue reading

Reading of the Week: The Case For Publicly Funded Therapy

It’s 4:30 on a Friday afternoon at her Sherbrooke, Que., clinic and Marie Hayes takes a deep breath before opening the door to her final patient of the day, who has arrived without an appointment. The 32-year-old mother immediately lists her complaints: She feels dizzy. She has abdominal pain. “It is always physical and always catastrophic,” Dr. Hayes will later tell me. In the exam room, she runs through the standard checkup, pressing on the patient’s abdomen, recording her symptoms, just as she has done almost every week for months. “There’s something wrong with me,” the patient says, with a look of panic.

Dr. Hayes tries to reassure her, to no avail. In any case, the doctor has already reached her diagnosis: severe anxiety. Dr. Hayes prescribed medication during a previous visit, but the woman stopped taking it after two days because it made her nauseated and dizzy. She needs structured psychotherapy – a licensed therapist trained to bring her anxiety under control. But the wait list for public care is about a year, says Dr. Hayes, and the patient can’t afford the cost of private sessions.

Meanwhile, the woman is paying a steep personal price: At home, she says, she spends most days in bed… Dr. Hayes does her best, spending a full hour trying to calm her down, and the woman is less agitated when she leaves.

But the doctor knows she will be back next week.

So begins an article from The Globe asking a simple question: should we publicly fund psychotherapy? In this week’s Reading, “The case for publicly funded therapy,” Erin Anderssen argues yes.

http://www.theglobeandmail.com/life/the-case-for-publicly-funded-therapy/article24567332/

Anderssen’s piece opened the The Globe and Mail’s excellent new series on mental health, which covers everything from the potential of technology to the search for biological markers. Continue reading

Reading of the Week: The Kids are Alright – The New England Journal of Medicine and Childhood Mental Health Disorders

The rate of severe mental illness among children and adolescents has dropped substantially in the past generation, researchers reported Wednesday, in an analysis that defies public perceptions of trends in youngsters’ mental health.

So begins The New York Times’ front-section coverage of a big paper in a big journal with a big result.

This paper, just published by The New England Journal of Medicine, considers the rate and treatment of childhood mental health impairment. In contrast to other surveys, this paper didn’t find a rise in the rate of mental illness. (Contrast this finding with the comment of a former president of the American Psychiatric Association that such illnesses are “an epidemic hidden in plain view” – that is, obviously there but underreported historically.)

Explains the lead author, Dr. Mark Olfson:

The finding is robust and real and challenges the prevailing stereotype that young people are somehow more vulnerable to mental problems.

Dr. Mark Olfson

How common is mental impairment among children and adolescents? How has this changed in recent years? How are patients being treated? Are we prescribing more than in the past? Olfson et al. seek answers to these important questions in “Trends in Mental Health Care among Children and Adolescents” – this week’s Reading. Continue reading

Reading of the Week: Dr. Gawande and ‘Low-Value Care’

It was lunchtime before my afternoon surgery clinic, which meant that I was at my desk, eating a ham-and-cheese sandwich and clicking through medical articles. Among those which caught my eye: a British case report on the first 3-D-printed hip implanted in a human being, a Canadian analysis of the rising volume of emergency-room visits by children who have ingested magnets, and a Colorado study finding that the percentage of fatal motor-vehicle accidents involving marijuana had doubled since its commercial distribution became legal. The one that got me thinking, however, was a study of more than a million Medicare patients. It suggested that a huge proportion had received care that was simply a waste.

The researchers called it “low-value care.” But, really, it was no-value care. They studied how often people received one of twenty-six tests or treatments that scientific and professional organizations have consistently determined to have no benefit or to be outright harmful.

So begins Dr. Atul Gawande’s recent essay in The New Yorker, which I have chosen as this week’s Reading.

It asks a simple question: what can we do about this?

Dr. Atul Gawande

Dr. Gawande, a general surgeon at Brigham and Women’s Hospital, is a prolific writer; he is a frequent contributor to The New Yorker and has penned several bestselling books, including Being Mortal and The Checklist Manifesto.

In this piece, Dr. Gawande focuses on overtreatment. Indeed, the title is a good summary: “Overkill.” Continue reading